Please fill out the following form to ensure that services are properly prepared for. Failure to disclose accurate information could result in a termination of services. All client information is private and secured in accordance with the HIPPA act.

First Name

Last Name

Address

City

State

Zipcode

Do you acccept all responsibilities and results of permanent makeup?

Yes

Do you accept that refusal of touch up can and will result in an unfinished looked?

Yes

Do you accept that you will void any gaurantees of shape, color, and retention due to refusal of touch up?

Yes

Do you accept additional charges will be included if you decide that you want touch ups outside of the offered 6-8 week touch up??

Yes

Signature

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